Describe cafe coronary with its mechanism and management.

Definition and Mechanism

• The term was coined by Roger HAUGEN in 1963, who recognised that a series of restaurant deaths attributed to heart attacks were in fact choking
• The mechanism has two components — mechanical obstruction of the larynx by the bolus; and, more importantly in the very rapid cases, vagal inhibition from stimulation of the laryngeal mucosa, causing instantaneous reflex cardiac arrest. This explains why death may occur in seconds, far faster than asphyxia would allow
• Predisposing factors — alcohol, which is present in most cases and impairs the protective reflexes and the coordination of swallowing; ill-fitting dentures or the absence of teeth, so that food is inadequately chewed and the palate cannot sense the bolus; old age; laughing or talking while eating; large poorly chewed pieces of meat, which is the classical bolus; neurological disease with impaired swallowing, including stroke and Parkinsonism; and mental illness or sedative drugs
• Why it resembles a heart attack — a middle-aged or elderly person at a meal suddenly stops, is unable to speak or breathe, clutches at the throat and chest, becomes cyanosed and collapses. Bystanders, and often doctors, assume a cardiac event; and the person is left to die while cardiac resuscitation is attempted

Findings and Management

• Autopsy findings — the bolus impacted in the larynx or at the laryngeal inlet, typically a piece of meat; marked congestion and cyanosis of the face; petechiae where death was not instantaneous; and often NO other abnormality. Where death was by vagal inhibition the asphyxial signs may be entirely absent, and the only finding is the bolus
• The airway must be examined IN situ, before the tongue and neck organs are removed; the bolus is easily dislodged during removal and then lies in the mouth or is lost, and the diagnosis is missed. This is the single most important technical point
• Coexisting coronary disease is common in this age group and must not be accepted as the cause of death without excluding the airway — which is precisely the error the term was invented to warn against
• Management in the living — recognise the universal choking sign and confirm the person cannot speak; encourage coughing if the obstruction is partial; give back blows between the scapulae and abdominal thrusts (the heimlich manoeuvre) alternately for complete obstruction; use chest thrusts instead in pregnancy and in the obese; and in an infant, back blows and chest thrusts, never abdominal thrusts. If the person becomes unconscious, begin chest compressions, which generate airway pressure, and look in the mouth at each cycle. Laryngoscopy with Magill forceps, and cricothyroidotomy as a last resort

Medicolegal Aspects and Applied Aspects

• The manner is accidental in almost all cases; but the death is medicolegal, being sudden and unexpected, and requires a full autopsy
• Questions that arise — whether the death was natural (a heart attack) or accidental (choking), which affects insurance and compensation since accidental death policies pay differently; whether there was negligence in an institution — a hospital, psychiatric facility or care home — where a patient known to have swallowing difficulty was left unsupervised or given unsuitable food; and rarely whether food was forced into the mouth, which would be homicide
• Examine the airway in situ in every sudden death at a meal; the diagnosis is entirely missed if the neck organs are removed first, and the family will be told the person died of a heart attack
• Ask about alcohol and dentures, and record the state of the dentition; both are present in the great majority of cases and support the diagnosis
• Do not accept coronary atherosclerosis as the cause without having looked at the larynx; incidental coronary disease is almost universal at this age and is the trap the term exists to describe
• Teach the choking sign; "can you speak?" is the whole of the differential diagnosis at the table, and abdominal thrusts by a bystander save lives that no hospital treatment could
• Vagal inhibition explains the speed; laryngeal stimulation causes instantaneous cardiac arrest, far faster than asphyxia would allow
• Alcohol and dentures are present in most cases, and their absence should make one look harder for another explanation
• Back blows and abdominal thrusts alternately for complete obstruction; chest thrusts instead in pregnancy and in the obese
• Never abdominal thrusts in an infant — back blows and chest thrusts only, because the abdominal viscera are unprotected by the rib cage
• Chest compressions generate airway pressure, so they are begun if the choking person becomes unconscious and may themselves expel the bolus
• The death is medicolegal and requires a full autopsy, since it is sudden and unexpected and the manner may be disputed
• Consider institutional negligence where a patient known to have swallowing difficulty was given unsuitable food or left unsupervised